Closed Case Friday: The Woman with Sudden & Referred Pain

Earlier this week, we gave you a hypothetical patient with the following case:

This week's hypothetical patient is a 25-year-old female who is admitted to the ER with sharp abdominal pains, vomiting, dizziness, nausea, and weakness. Her boyfriend, who brought her into the ER, states that her pain began suddenly and that she said she felt as if she were going to faint all the way to the hospital. Because she was stable upon arrival, a physical examination was done. When asked if she could be pregnant, she stated that she could not be as she has an IUD, but did acknowledge that the couple were sexually active. She also stated that she had missed her last period, but assumed it was because she had recently started training for a 5K and was trying to quit smoking. The patient's vital signs were normal. The patient was experiencing diffuse abdominal tenderness. During the exam, the patient began to bleed vaginally and started feeling pain in her shoulder that radiated up to her neck. She was immediately given a FAST (focused assessment with sonography in trauma) exam. An OB/Gyn was called in for an emergency surgical consultation.

Today, we reveal that our hypothetical patient was diagnosed as having: 

Ectopic Pregnancy with Fallopian Tube Burst 

This patient had many of the classic symptoms of ectopic pregnancy, including abdominal pain, weakness, dizziness, nausea, and vomiting. She also had many of the risk factors, such as smoking, a missed period, and an IUD. Becoming pregnant while having an IUD is rare, but those who do become pregnant while having an IUD are more likely for the pregnancy to be ectopic. A tubal ligation also increases the risk of ectopic pregnancy if a woman becomes pregnant following this procedure. Smoking can also increase the risk of ectopic pregnancy. In this case, the patient's Fallopian tube burst, causing the vaginal bleeding. The internal pooling of blood following the bursting of a Fallopian tube can occur near the diaphragm and irritate nerves that run into the shoulder and neck, which can lead to the referred pain that this patient experienced. The FAST exam likely showed the damaged Fallopian tube and internal bleeding, which led to calling in an OB/Gyn for a surgical consultation. The classic triad for the clinical presentation of ectopic pregnancy is abdominal pain, vaginal bleeding, and a missed menstrual period. This typically presents 6-8 weeks after the last normal menstrual period. Rupture of the Fallopian tubes may be suggested by severe abdominal pain, nausea, vomiting, lightheadedness, referred pain (to the shoulder, neck, or rectum), and/or abnormalities in the vital signs, including hypotension, tachycardia, or shock. Early diagnosis of ectopic pregnancy can often be managed with medicine if there is no damage to the Fallopian tube. This is typically done using an injection of methotrexate (Trexall), which stops the cells from growing and allows the body to absorb the pregnancy. In cases where this medication doesn't work, or a woman has severe symptoms, such as a ruptured Fallopian tube, surgery is the only option. Surgeons prefer doing laproscopic surgery when possible, but in our patient's case, a larger incision would likely be necessary as her Fallopian tube might have to be removed. After surgery, the patient's hCG levels will be closely monitored to make sure that the pregnancy was properly removed.

Thanks for joining us for this week's Mystery Case and we hope to see you next week!